You’ve done everything right. Your doctor diagnosed a complex condition and prescribed a specific, critical treatment—a new biologic, a specialized MRI, or a precise surgical procedure. Your clinical team submitted the detailed prior authorization (PA). You waited. And then comes the devastating news: the insurance company’s automated system or an anonymous reviewer has issued a denial, claiming the service is “not medically necessary.” It can feel final, but it usually is not.
Many patients stop here. Yet a denial often opens the door to a clinical conversation. Most insurers offer a Peer-to-Peer (P2P) Review: a phone call in which your treating physician speaks directly with a physician reviewer or medical director at the plan. When it is available, it can be one of the quickest ways to get a denial reconsidered, sometimes before a formal written appeal is needed. It does not replace your appeal rights, and it is not guaranteed to succeed.
A productive call depends on preparation, not volume. This guide explains how the process generally works and how your medical team can prepare, so you know what to ask your doctor’s office to do.
1. What a Peer-to-Peer Review Is (and Is Not)
The idea behind a peer-to-peer review is simple: a physician who knows the patient explains the case to a physician who works for the plan. Initial reviews are often based on a checklist of coverage criteria and whatever records were attached to the request, so important context can be missing. A conversation gives your doctor a chance to fill in those gaps.
Peer-to-peer review is mostly a matter of insurer policy and, in some places, state law or accreditation standards. It is not a universal federal right, and availability, deadlines and procedures vary by plan. Some plans allow the call only within a short window after the denial, and some offer it only before a formal appeal is filed. The denial letter or the plan’s provider line will explain how to request one.
Separately, federal rules do give most patients the right to a written explanation of a denial, an internal appeal and, for many plans, an external review. Recent federal prior authorization rules also require certain payers to give specific reasons for denials and to respond within set timeframes. If the peer-to-peer call does not change the outcome, those formal rights remain available.
2. Operational Differences: Peer-to-Peer vs. Standard Appeals
A Peer-to-Peer consultation is fundamentally different from a written appeal. The main differences are the format and the speed. The table is a general comparison; your plan’s timelines may differ:
Written Appeals vs. Peer-to-Peer
| Review Metric | Standard Written Appeal | Peer-to-Peer Review |
|---|---|---|
| Decision Mechanism | Review of written records by the plan’s appeal staff. | A live phone conversation between two physicians. |
| Turnaround Time (TAT) | Often up to about 30 days for pre-service appeals; faster for expedited appeals in urgent cases. | Often scheduled within a few days; the reviewer may decide on the call or shortly after. |
| Evidence Review | Based on the written record, including any new documents you submit with the appeal. | Your doctor can explain context and point to how the plan’s criteria are met. |
| Physician Availability | Handled on paper; the treating doctor does not need to be on a call. | Requires the treating clinician to be available for the scheduled call. |
| Outcome | Varies; creates a formal record and preserves the right to external review. | Varies by plan and case; a well-prepared call can resolve some denials quickly. |
3. How to Prepare for the Call: A 4-Step Approach
Success on a peer-to-peer call depends on preparation and on speaking the plan’s language. These are steps your doctor’s office can take before the scheduled call:
Step 1: Work From the Plan’s Own Coverage Policy
Saying “trust me, the patient needs this” rarely works. Reviewers apply a written document, often called a clinical policy bulletin, medical policy or coverage policy, and many insurers publish these online. Before the call, the office can:
- Pull up the insurer’s policy for the requested treatment.
- Identify the criteria the denial letter says were not met.
- Match each criterion to a specific place in the chart, for example: “The progress note from March documents that the patient tried and did not respond to drug X, which is the step-therapy requirement in your policy.”
Step 2: Ask for a Same-Specialty Reviewer (When Possible)
The plan’s reviewer may not practice in the same specialty as your doctor. Your physician can ask whether a same-specialty reviewer is available. For example, a neurologist discussing a headache treatment might ask, “Is a neurologist available to review this case?” Plans are not always required to provide one at this stage, but some states and plans do call for same-specialty review on appeal, and it is reasonable to ask.
Step 3: Explain the Patient’s Specific Situation and Any Urgency
A checklist cannot capture everything about a patient. On the call, your doctor can describe what makes your case different: what has already been tried, how the condition affects daily function, and what is likely to happen without the treatment. If a delay could seriously jeopardize your health, your doctor should say so clearly and ask that the request be handled as urgent. Federal claims rules for many employer plans define urgent care claims and require faster decisions on them, and a treating physician’s statement that a case is urgent carries significant weight under those rules.
Step 4: If the Answer Is Still No, Get the Reason in Detail
If the reviewer upholds the denial, your doctor can ask: “Which specific criteria in your coverage policy does this patient not meet, and what documentation would change the decision?” The answer tells you exactly what to address in a written appeal and, if needed, in an external independent review, where a reviewer outside the insurance company looks at the case.
4. What You Can Do as the Patient
Patients usually cannot join the call, but you can make it more likely to happen and to go well:
- Call your doctor’s office as soon as you receive the denial. Ask whether they plan to request a peer-to-peer review and whether there is a deadline for doing so.
- Send them the denial letter. The office may not have received the same letter you did. The stated reason for denial is what the call needs to address.
- Share your history. Write a short list of treatments you have already tried, with approximate dates and what happened. Records from other clinics may not be in your current doctor’s chart.
- Ask for the outcome. After the call, ask what the reviewer decided and why.
- Keep your appeal clock in view. A peer-to-peer request does not necessarily pause the deadline for a formal appeal. Note the appeal deadline on the denial letter; our guide to appeal deadlines explains the stages.
5. A Worked Example (Hypothetical)
This example is hypothetical. A patient with chronic back pain is denied an MRI because the plan’s policy requires six weeks of conservative treatment first, and the request did not mention any. In fact, the patient completed eight weeks of physical therapy at a different clinic. The patient tells the doctor’s office, which obtains the therapy records and requests a peer-to-peer call. On the call, the doctor points to the therapy dates and the lack of improvement. Because the missing criterion is now documented, the reviewer has a basis to approve the request.
The lesson is that many denials turn on missing information rather than a real disagreement about care. When the disagreement is real, the call may not change the result, and a written appeal is the next step.
6. Common Mistakes to Avoid
- Missing the window. Some plans allow a peer-to-peer call only for a limited time after the denial.
- Treating the call as the appeal. It is usually an informal step. If it fails, file the formal appeal on time. Our appeal letter framework can help.
- Going in without the policy. A call that does not address the plan’s stated criteria is unlikely to succeed.
- Sending someone unfamiliar with the case. The call is most effective when the clinician who knows your history takes part.
- Not asking for the decision in writing. Keep the letter for your records, whichever way it goes.
Frequently Asked Questions
Can I request a peer-to-peer review myself?
Usually the treating provider requests and takes part in it. Your role is to ask your doctor’s office to do so and to supply any information they need.
Does every plan offer peer-to-peer review?
No. It is common but not universal, and the rules differ by plan and state. The denial letter or the plan’s provider services line will say whether it is available.
Does a peer-to-peer call cost anything?
Plans do not charge for it. It does take your doctor’s time, which is one reason offices sometimes need a reminder.
What if my doctor’s office will not request one?
Ask whether they will support a written appeal instead, for example with a letter of medical necessity. You can generally file an appeal yourself.
What if the denial is upheld?
You still have formal appeal rights and, for many plans, the right to an external review. If you believe the plan is not following its own procedures, your state insurance department or, for employer plans, the U.S. Department of Labor can explain your options.
The Bottom Line
A medical necessity denial is often the start of a process, not the end of it. Where it is offered, a peer-to-peer review gives your doctor a chance to explain your case directly to a physician at the plan, and a well-prepared call can sometimes resolve a denial quickly. It is not guaranteed, so keep track of your formal appeal deadlines and be ready to use them.
This article is educational information, not legal, medical or financial advice.